International Journal of Keratoconus and Ectatic Corneal Diseases

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VOLUME 8 , ISSUE 1 ( January-June, 2019 ) > List of Articles


Association of Ferrara Intracorneal Ring Segments with Phakic Intraocular Lens for Improved Visual Acuity in Young Keratoconus Patients: A Case Series

Edna M Almodin, Flávia Almodin, Juliana Almodin

Keywords : Intracorneal ring segments, Keratoconus, Phakic lens

Citation Information : Almodin EM, Almodin F, Almodin J. Association of Ferrara Intracorneal Ring Segments with Phakic Intraocular Lens for Improved Visual Acuity in Young Keratoconus Patients: A Case Series. Int J Kerat Ect Cor Dis 2019; 8 (1):23-28.

DOI: 10.5005/jp-journals-10025-1175

License: CC BY-NC 4.0

Published Online: 23-07-2020

Copyright Statement:  Copyright © 2019; The Author(s).


Aim: We present a case series involving five eyes in four young patients with advanced keratoconus who were implanted with Ferrara intrastromal corneal ring segments (ICRS) followed by phakic intraocular lens (PIOLs). Background: ICRS have been used for the management of keratoconus in order to prevent further keratoconus progression and improve visual performance. Nonetheless, many patients may still suffer from moderate to high myopia after ICRS, requiring refractive error correction, which may not be achieved with glasses, contact lenses, or laser refractive surgery. For such cases, PIOLs have emerged as an alternative to correct residual refractive errors. Case description: Patients were aged between 13 years and 32 years at ICRS implantation. Around 6 months after ICRS implantation, patients were submitted to a second procedure for the implantation of an implantable collamer lens (ICL), Artisan or Artiflex PIOL to correct residual myopia. After the combined Ferrara ICRS and PIOL implantation, all treated eyes demonstrated a significant improvement in topographic findings and visual acuity, with reduced refraction and keratometric astigmatism. Conclusion: The combined procedure was successful in reshaping the cornea and improving visual acuity of patients. Clinical significance: The association of ICRS and PIOL can be an important alternative that should be considered to provide young patients with improved visual acuity in a moment of their lives when they are at their most productive phase.

  1. Rabinowitz YS. Keratoconus. Surv Ophthalmol 1998;42(4):297–319. DOI: 10.1016/S0039-6257(97)00119-7.
  2. Jhanji V, Sharma N, Vajpayee RB. Management of keratoconus: current scenario. Br J Ophthalmol 2011;95(8):1044–1050. DOI: 10.1136/bjo.2010.185868.
  3. Hamdi IM. Preliminary results of intrastromal corneal ring segment implantation to treat moderate to severe keratoconus. J Cataract Refract Surg 2011;37(6):1125–1132. DOI: 10.1016/j.jcrs.2010.12.048.
  4. Lago MA, Ruperez MJ, Monserrat C, et al. Patient-specific simulation of the intrastromal ring segment implantation in corneas with keratoconus. J Mech Behav Biomed Mater 2015;51:260–268. DOI: 10.1016/j.jmbbm.2015.07.023.
  5. Chan E, Snibson GR. Current status of corneal collagen cross-linking for keratoconus: a review. Clin Exp Optom 2013;96(2):155–164. DOI: 10.1111/cxo.12020.
  6. Viswanathan D, Kumar NL, Males JJ. Outcome of corneal collagen crosslinking for progressive keratoconus in paediatric patients. Biomed Res Int 2014;2014:140461. DOI: 10.1155/2014/140461.
  7. Ivarsen A, Hjortdal J. Collagen cross-linking for advanced progressive keratoconus. Cornea 2013;32(7):903–906. DOI: 10.1097/ICO.0b013e31828321dd.
  8. Coskunseven E, Onder M, Kymionis GD, et al. Combined Intacs and posterior chamber toric implantable Collamer lens implantation for keratoconic patients with extreme myopia. Am J Ophthalmol 2007;144:387–389. DOI: 10.1016/j.ajo.2007.05.035.
  9. Uçakhan OO, Kanpolat A, Ozdemir O. Contact lens fitting for keratoconus after Intacs placement. Eye Contact Lens 2006;32:75–77. DOI: 10.1097/
  10. Hladun L, Harris M. Contact lens fitting over intrastromal corneal rings in a keratoconic patient. Optometry 2004;75:48–54. DOI: 10.1016/S1529-1839(04)70010-X.
  11. El Danasoury MA, El Maghraby A, Gamali TO. Comparison of iris-fixed Artisan lens implantation with excimer laser in situ keratomileusis in correcting myopia between -9.00 and -19.50 diopters: a randomized study. Ophthalmology 2002;109(5):955–964. DOI: 10.1016/S0161-6420(02)00964-8.
  12. Malecaze FJ, Hulin H, Bierer P, et al. A randomized paired eye comparison of two techniques for treating moderately high myopia: LASIK and artisan phakic lens. Ophthalmology 2002;109(9):1622–1630. DOI: 10.1016/S0161-6420(02)01164-8.
  13. Alfonso JF, Lisa C, Fernández-Vega L, et al. Intrastromal corneal ring segments and posterior chamber phakic intraocular lens implantation for keratoconus correction. J Cataract Refract Surg 2011;37(4):706–713. DOI: 10.1016/j.jcrs.2010.10.060.
  14. Kamburoğlu G, Ertan A, Bahadir M. Implantation of Artisan toric phakic intraocular lens following Intacs in a patient with keratoconus. J Cataract Refract Surg 2007;33(3):528–530. DOI: 10.1016/j.jcrs.2006.10.047.
  15. Coullet J, Guëll JL, Fournié P, et al. Iris-supported phakic lenses (rigid vs foldable version) for treating moderately high myopia: randomized paired eye comparison. Am J Ophthalmol 2006;142(6):909–916. DOI: 10.1016/j.ajo.2006.07.021.
  16. Siganos D, Ferrara P, Chatzinikolas K, et al. Ferrara intrastromal corneal rings for the correction of keratoconus. J Cataract Refract Surg 2002;28(11):1947–1951. DOI: 10.1016/S0886-3350(02)01495-5.
  17. Miranda D, Sartori M, Francesconi C, et al. Ferrara Intrastromal Corneal Ring Segments for Severe Keratoconus. J Refract Surg 2003;19(6):645–653.
  18. Ameerh MA, Hamad GI, Ababneh OH, et al. Ferrara ring segments implantation for treating keratoconus. Int J Ophthalmol 2012;5(5): 586–590. DOI: 10.3980/j.issn.2222-3959.2012.05.08.
  19. Shabayek MH, Alio JL. Intrastromal corneal ring segment implantation by femtosecond laser for keratoconus correction. Ophthalmology 2007;114:1643–1652. DOI: 10.1016/j.ophtha.2006.11.033.
  20. Torquetti L, Berbel RF, Ferrara P. Long-term follow-up of intrastromal corneal ring segments in keratoconus. J Cataract Refract Surg 2009;35:1768–1773. DOI: 10.1016/j.jcrs.2009.05.036.
  21. Ambrósio Jr R. Intracorneal ring segment, phakic IOL implantation enable keratoconus management without keratoplasty. Ocular Surgery News 2011.
  22. Dick HB, Budo C, Malecaze F, et al. Foldable Artiflex phakic intraocular lens for the correction of myopia: two-year follow-up results of a prospective European multicenter study. Ophthalmology 2009;116(4):671–677. DOI: 10.1016/j.ophtha.2008.12.059.
  23. Sanders DR, Doney K, Poco M. ICL in Treatment of Myopia Study Group. United States Food and Drug Administration clinical trial of the implantable collamer lens (ICL) for moderate to high myopia: three-year follow-up. Ophthalmology 2004;111(9):1683–1692. DOI: 10.1016/j.ophtha.2004.03.026.
  24. Al Sabaani N, Al Assiri A, Al Torbak A, et al. Outcome of posterior chamber phakic intraocular lens procedure to correct myopia. Saudi J Ophthalmol 2013;27(4):259–266. DOI: 10.1016/j.sjopt.2013.06.009.
  25. Budo C, Hessloehl JC, Izak M, et al. Multicenter study of the Artisan phakic intraocular lens. J Cataract Refract Surg 2000;26:1163–1171. DOI: 10.1016/S0886-3350(00)00545-9.
  26. Benedetti S, Casamenti V, Benedetti M. Long-term endothelial changes in phakic eyes after Artisan intraocular lens implantation to correct myopia: five-year study. J Cataract Refract Surg 2007;33: 784–790. DOI: 10.1016/j.jcrs.2007.01.037.
  27. Pop M, Payette Y. Initial results of endothelial cell counts after Artisan lens for phakic eyes: an evaluation of the United States Food and Drug Administration Ophtec study. Ophthalmology 2004;111:309. DOI: 10.1016/j.ophtha.2003.05.025.
  28. Tahzib NG, Nuijts RM, Wu WY, et al. Long-term study of Artisan phakic intraocular lens implantation for the correction of moderate to high myopia: ten-year follow-up results. Ophthalmology 2007;114: 1133–1142. DOI: 10.1016/j.ophtha.2006.09.029.
  29. Nassiri N, Ghorbanhosseini S, Jafarzadehpur E, et al. Visual acuity, endothelial cell density and polymegathism after iris-fixated lens implantation. Clin Ophthalmol 2018;12:601–605. DOI: 10.2147/OPTH.S157501.
  30. Saxena R, Boekhoorn SS, Mulder PG, et al. Long-term follow-up of endothelial cell change after Artisan phakic intraocular lens implantation. Ophthalmology 2008;115(4):608e1–613e1. DOI: 10.1016/j.ophtha.2007.05.036.
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